Provider Demographics
NPI:1922629252
Name:ACEBO, SEVERIANO BROCK (DO)
Entity Type:Individual
Prefix:DR
First Name:SEVERIANO
Middle Name:BROCK
Last Name:ACEBO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 HOLCOMB BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:U.S. MARINE CORPS FORCES COMMAND
Practice Address - Street 2:1775 FORRESTAL DRIVE BLDG 33
Practice Address - City:NORFOLK, VA
Practice Address - State:VA
Practice Address - Zip Code:23551
Practice Address - Country:US
Practice Address - Phone:910-450-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02482171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider